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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700301
Report Date: 03/07/2022
Date Signed: 03/07/2022 01:25:13 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/20/2021 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211220090441
FACILITY NAME:COUNTRY CLUB MANORFACILITY NUMBER:
342700301
ADMINISTRATOR:CISCOE, MARIAFACILITY TYPE:
740
ADDRESS:2100 BUTANO DRIVETELEPHONE:
(916) 481-9240
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:112CENSUS: 54DATE:
03/07/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Maricar VenegasTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Residents are not being provided activities
-Food services are inadequate
INVESTIGATION FINDINGS:
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On 3/7/2022 at 11:25 AM, Licensing Program Analyst (LPA) Chris Hopkins arrived at this facility unannounced to conduct a complaint investigation regarding the above allegations. LPA met with Administrator Maricar Venegas and explained the purpose of today's visit.

Regarding the allegation of Residents are not being provided activities, the Department found the following:
based on interviews and record review, it was determined that due to Covid-19 the normal activities were put on pause to prevent further breakouts, but Administrator did provide residents with in room activities such as word puzzels, word searches, reading, and bingo.

Regarding the allegation of Food services are inadequate, the Department found the following: based on interviews, it was determined Resident 1 (R1) often did not want to eat what was prepared. The facility has always had alternative options for cases when residents don't want to eat what is on the menu.
Report continued on LIC9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20211220090441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY CLUB MANOR
FACILITY NUMBER: 342700301
VISIT DATE: 03/07/2022
NARRATIVE
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Residents are provided with alternative menu sheets to fill out if they dont want to eat what is being served that day. During isolation the kitchen staff prepared food and placed it on 2 different carts to be delivered by caregivers. Once all placed on the cart, it was immediately delivered to resident rooms.

LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator Maricar Venegas. A copy of this report was left with Administrator upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2